The treatment of HIV is through antiretroviral therapy (the HIV virus is called a 'retrovirus' in medical terms). Another term for antiretroviral therapy is HAART or ART (Highly Active AntiRetroviral Therapy or AntiRetroviral Therapy). These are all terms for the same treatment: a combination of different anti-viral medicines that fight the HIV virus, or a combination of different HIV inhibitors.
HIV infection is always treated with a combination of (usually two or three) different drugs. It has been found that when only one HIV inhibitor is used, the virus quickly becomes resistant to the drug and then the drug no longer works.
There are now many different types of HIV inhibitors in circulation and within each type there are different individual medicines. Since 2022, HIV inhibitors have come on the market that can be given intramuscularly (via an injection in the buttock). This is called long acting therapy. The advantage is that this only needs to be done once every two months. The disadvantage is that not everyone is eligible for this: you must be stable on therapy for a year anyway, you must not have resistances in the virus and you must not have a hepatitis B infection.
Not every combination of tablets or injections is suitable for every patient. Which combination of resources is chosen depends on a number of factors:
- Resistance to the HIV virus: a resistance test is always performed prior to treatment to see whether the virus you are infected with is sensitive to certain HIV inhibitors.
- Other illnesses or infections: some patients have, in addition to the HIV infection, another condition (for example, diabetes or hepatitis B infection) that makes the use of some medicines undesirable.
- The expected side effects of the individual drugs from the combination; a dreaded side effect is, for example, lipodystrophy, the disappearance of subcutaneous fatty tissue in the face and limbs. The drugs known for this side effect are avoided as much as possible.
- The number of tablets in a given combination. Some HIV inhibitors have been combined in one pill, with taking one pill you use two or even three medicines at the same time.
- Frequency of intake: some combinations require once-daily tablet intake, other combinations require twice-daily intake.
- Patient's lifestyle and rhythm of life.
When choosing the specific combination, the patient's wishes always come first. The internist and nurse consultant will only provide information about the different options and advise on the best options, but the patient ultimately decides which combination it will be.
When to start treatment?
It is a big step for most patients to start taking medication. At the moment it still looks like HIV inhibitors (ART) will have to be used for life. This is because the current generation of HIV inhibitors only suppress the HIV virus but do not completely eradicate it from the body. When ART is stopped, the concentration of the HIV virus in the blood usually quickly rises again. Many patients find the thought of having to take medicines for the rest of their lives frightening. In addition, patients often fear the possible side effects of ART. Many older HIV inhibitors caused lipodystrophy in some of the patients: this is a condition in which the subcutaneous fatty tissue disappears from the face and limbs and increases in the abdomen. This side effect is seen much less often with the newer drugs. But invisible side effects (such as an increase in cholesterol, kidney function disorders and osteoporosis) can also occur when using ART.
Despite possible negative aspects of anti-HIV therapy, the advice is nowadays to start treatment immediately or at least soon after making the diagnosis. Research has shown that patients who started therapy quickly ultimately have a better life expectancy than patients who wait a long time before starting treatment.
In addition, in the case of an acute HIV infection, the reservoirs (areas in the body where the HIV is stored) in the body are not yet full of HIV particles, so it is good to start before this is the case.
However, there are still a number of factors that are taken into account when starting treatment:
- Patient motivation:
Without a good motivation to start with medication, it has been found that a treatment is often less successful. With HIV inhibitors, it is important that you take the pills at about the same time each day. When a patient is not well motivated, you see that he or she more often shifts the time of intake or even forgets to take the pills for a day. If this happens more often, the virus can develop resistance to the drugs used and you will see the amount of HIV in the blood increase again.
- Other circumstances:
Sometimes someone wants to bring the treatment forward or postpone it because of other circumstances in his/her life, such as a vacation or a new job.
In certain circumstances the current treatment composition is changed, this is called switching. The most common circumstances to switch are:
- Viral failure: this means that the amount of HIV virus in the blood increases again despite taking medication. This is usually caused by resistance of the virus to one or more drugs of the current combination therapy.
- Side effects of one or more drugs of the current combination therapy: both noticeable side effects for the patient (e.g. severe skin rash, lipodystrophy, nausea, diarrhoea) and non-noticeable side effects (e.g. increase in cholesterol or reduced function of the kidneys) can be a reason for the medicines to change the combination.
- Improvement of old treatment: new HIV inhibitors keep coming onto the market, which is why it is possible that better medicines are now available than those the patient is currently taking. The new medicines often have fewer side effects or are easier to take (once a day instead of twice a day or two or more medicines in a combined pill).
- Other reasons such as co-infections or other concomitant diseases.
- Patient's wish: sometimes the patient has heard about another therapy and asks if it is possible to use it.
A therapy switch is always discussed in detail with the patient in advance. This conversation explains the motivation for switching and what can be expected from the new therapy. The wishes and preferences of the patient again play a major role in the choice of the new therapy. If the HIV viral load is undetectable during the switch, the current ART will continue to work; so you can always switch back.